A 56-year-old woman comes to the office for a routine health maintenance evaluation. The patient is physically well but reports feeling upset that she had to place her 79-year-old father in a nursing home. She says, "I've cared for him since he developed Alzheimer disease 5 years ago, but I couldn't manage him at home anymore." The patient's medical conditions include hypertension and type 2 diabetes mellitus. She underwent menopause at age 51. She does not use tobacco or alcohol and takes yoga classes 3 times a week. Blood pressure is 140/85 mm Hg and pulse is 77/min. BMI is 32 kg/m². Physical examination is unremarkable. The patient expresses concern about developing Alzheimer disease like her father and asks if there is anything to do. Which of the following is the most appropriate response to the patient?

Question

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Alzheimer disease (AD) is the most common form of dementia (ie, major neurocognitive disorder), and patients with a family history of AD will frequently have questions and concerns about their risk of developing the disease. Although this patient is at increased risk based on her father's history, addressing modifiable risk factors can reduce the likelihood of developing AD. Evidence shows that aggressive treatment of cardiovascular risk factors (eg, hypertension, diabetes, obesity/physical inactivity), especially in mid-life, can help reduce risk. For this patient, optimizing control of hypertension and diabetes, encouraging weight loss, and suggesting increased physical activities are all potentially helpful interventions to reduce her risk of developing AD. In addition to controlling this patient's cardiovascular risk factors, engaging in cognitively stimulating activities and maintaining social relationships may also modify the progression of cognitive impairment in patients at risk for AD. There is no convincing evidence that taking supplements (eg, vitamin E, other antioxidant vitamins, gingko biloba) can prevent the development of AD (Choice B). There is conflicting evidence of symptomatic benefit for the use of vitamin E in patients already diagnosed with mild to moderate AD. (Choice A) Although early-onset AD (onset age ≤65) is more heritable than late-onset forms (onset age >65), this response suggests genetic risk does not play a role in late-onset AD, which is untrue. It also ignores this patient's modifiable risk factors. (Choice C) Although this response begins empathically, it may engender feelings of helplessness and fails to address modifiable risk factors. The physician should help the patient feel empowered by encouraging her to take steps to reduce her risk of developing AD by getting better control of her medical conditions and adopting a healthy lifestyle. (Choice D) The genetics of late-onset AD is complex and although patients who carry the APOE ε4 allele are at increased risk, almost 40% of patients with AD do not carry this allele. The physician would not be able to reassure this patient based on a negative result. At this time, APOE genotyping is mostly used as a research tool. Educational objective: Patients with a family history of Alzheimer disease are at increased risk of developing the disease but can mitigate risk by addressing modifiable risk factors. Aggressive treatment of cardiovascular risk factors (eg, hypertension, diabetes, obesity/physical inactivity), especially in mid-life, can help reduce risk. References: Alzheimer's disease: risk factors and potentially protective measures. (http://www.ncbi.nlm.nih.gov/pubmed/31072403) Treatment options and considerations for hypertensive patients to prevent dementia. (http://www.ncbi.nlm.nih.gov/pubmed/28532183)

A 56-Year-Old Woman Comes to the Office for a Routine